MAT in Drug Courts: Recommended Strategies

MedicationAssisted
Treatment in
Drug Courts
Recommended
Strategies
MedicationAssisted
Treatment in
Drug Courts
Recommended
Strategies
ii
Medication-Assisted Treatment in Drug Courts
Authors
Sally Friedman
Legal Director
Legal Action Center
Kate Wagner-Goldstein
Senior Staff Attorney
Legal Action Center
This project was supported by Statewide Enhancement Grant No. 2012-DCBX-0012 awarded by the Bureau of Justice Assistance. The Bureau of Justice
Assistance is a component of the Office of Justice Programs, which also includes
the Bureau of Justice Statistics, the National Institute of Justice, the Office of
Juvenile Justice and Delinquency Prevention, the Office for Victims of Crime, and
the SMART Office. Points of view or opinions in this document are those of the
authors and do not necessarily represent the official position or policies of the
U.S. Department of Justice.
Acknowledgements
The authors are grateful to the New York State Unified Court System and the
Center for Court Innovation for the opportunity to write this resource guide for
drug treatment courts that seek to incorporate medication-assisted treatment
into their programs. Specifically, the authors thank Valerie Raine, Statewide
Drug Court Coordinator, Kimberly Kozlowski, Project Manager for the Office of
Policy and Planning, and Robert Wolf, Communications Director at the Center
for Court Innovation, for their invaluable help in organizing, writing, and producing this document.
The authors appreciate the considerable time and distilled wisdom that New
Yorks drug treatment court staff contributed to this effort. Judges, coordinators,
and project directors from across the state provided a vast amount of
information about the benefits and challenges of implementing medication
assisted-treatment in their programs. Without their hands-on experience of
working with doctors, providers, and drug court participants, this document
would not have been possible.
Finally, the authors are grateful for the substantial help provided by Melissa
Trent, who works at the Legal Action Center as an Equal Justice Works Fellow
sponsored by the Friends and Family of Philip M. Stern.
iii
About the Legal Action Center

The Legal Action Center is the only non-profit law and policy organization
whose sole mission is to fight discrimination against people with histories of
addiction, HIV/AIDS, or criminal records, and to advocate for sound public
policies in these areas. The Legal Action Centers work over more than four
decades has helped to vastly increase alternatives to incarceration and achieve
historic sentencing reforms as well as dozens of other policies that promote a
public health approach to addiction, HIV/AIDS, and the criminal justice system.
About the Center for Court Innovation

The Center for Court Innovation is a non-profit organization that seeks to
help create a more effective and humane justice system by designing and
implementing operating programs, performing original research, and providing
reformers around the world with the tools they need to improve public safety,
reduce incarceration, and enhance public trust in justice.
About the New York State Unified Court Systems Office

of Policy and Planning
Under the direction of New Yorks Chief Judge, the New York State Unified Court
System serves nearly 19.5 million people. To meet this challenge, New York State
has approximately 1,300 judges, 2,300 town and village judges and 15,000
non-judicial employees working in over 300 state courts and 1,300 town and
village courts, spread throughout 62 counties in 13 judicial districts. The system
is supported by the Office of Court Administration. As the policy-making body of
the Office of Court Administration, the Office of Policy and Planning works with
judges statewide to study and develop new strategies to improve the delivery
of justice in New York. In addition, the Office of Policy and Planning provides
guidance, support, and comprehensive training programs to problem-solving
courts statewide.
2015
iv
Contents
Authors and Acknowledgements ii
Introduction
I. Medication-Assisted Treatment
II. Nine Components of Successful MAT Programs
12
III. Court Profiles
17
18
Central New York Treatment Court
Serving a mid-size city and nearby suburban and rural areas.
Upstate Treatment Court 29

Serving a small city and the surrounding suburban and rural areas.
Downstate Urban Treatment Court 38

Serving a densely populated county within a large city.
IV. Specific Issues for Rural Courts
45
Conclusion
48
Endnotes
50
Appendices
54
Introduction
Introduction
.BE IT RESOLVED THAT:

1. Drug Court professionals have an affirmative obligation to
learn about current research findings related to the safety and
efficacy of M.A.T for addiction.
2. Drug Court programs should make reasonable efforts to attain reliable expert consultation on the appropriate use of M.A.T.
for their participants.
3. Drug courts do not impose blanket prohibitions against the
use of M.A.T. for their participants. The decision whether or not
to allow the use of M.A.T. is based on a particularized assessment
in each case of the needs of the participants and the interests of
the public and the administration of justice. . . . .
National Association of Drug Court Professionals

Resolution of the Board of Directors
Introduction
Introduction
This report is designed to help drug court practitioners understand medicationassisted treatment (MAT) for opioid addiction and to provide strategies for
incorporating MAT into their practice. The reports information about different
MAT models can serve as a resource for courts that currently permit MAT as well
as those considering it. Though based on the experience of courts in New York
State, the reports recommendations are not state specific and can be applied to
courts around the country.
MAT involves the use of medications, in combination with counseling and
behavioral therapies, to provide a whole-patient approach to the treatment of
substance use disorders. When used to treat opioid addiction, MAT stabilizes
brain chemistry, blocks the euphoric effects of opioids (the high), relieves
physiological cravings, and normalizes body functions. Numerous studies have
shown that MAT reduces illicit drug use, disease rates, overdose, mortality, and
criminal behavior.
With the opioid epidemic ravaging communities across the country, there
has been an increasing call by the government, families, public health officials,
and others to use all tools available to treat opioid addiction and save lives. In
September 2015, New Yorks governor signed a law to create uniform access to
MAT in the states judicial diversion program.1 The law amended New Yorks
Criminal Procedure Law to explicitly state that judicial diversion programs may
include medically prescribed drug treatments for opioid abuse or dependence
and that participation in such treatment cannot be the basis for finding that a
defendant has violated release conditions.2
Strictly speaking, the new provisions apply only to cases processed under
Article 216the judicial diversion program for individuals charged with certain
felony offenses. Nevertheless, the legislative history evidences the unequivocal
intent to promote the use of MAT in drug treatment courts when prescribed by
an authorized and qualified physician:
[T]he World Health Organization has come out strongly in support of

continued use of such treatments, stating that clinical research has proven
that arbitrary limits on the use of methadone and buprenorphine therapy
treatments is disadvantageous to the ultimate goals of judicial drug
treatment programs. . . . While the legislature has the utmost respect for
judicial discretion, it is evident that prohibiting the use of methadone
and buprenorphine therapy treatment, or requiring its use merely as
a bridge to abstinence is contrary to established best practices, and
hinders the recovery process.3
Additionally the United States Department of Justices Bureau of Justice
Assistance and Substance Abuse and Mental Health Services Administration
recently began requiring that all drug courts receiving federal money permit
MAT. The 2015 Best Practices Standards Report issued by the National
Association for Drug Court Professionals also recommends that courts grant
access to addiction medications when recommended by a physician (see
Appendix B). Finally, prohibition of MAT can violate federal anti-discrimination
law protecting individuals with disabilities.4
Nevertheless, surveys reveal that only about half of the drug courts in the
United States permit participants to enroll in and be maintained on MAT.5
Reasons for denying access to MAT range from lack of knowledge about the
science of opioid addiction and the effectiveness of MAT, to the belief that taking
MAT is substituting one addiction for another, as well as concerns about the
practical implications of MAT within the drug court model.
The New York State Office of Court Administration held a training series
about MAT in 2014 and many participants had questions such as: How
can courts minimize illicit diversion of MAT medications? How can they
successfully monitor participants? How can they address opposition to MAT by
some members of the drug court team?
This report answers these and related questions while giving courts the
tools to comply with recent mandates and public health imperatives so that
they can improve participant outcomes by including MATwhen prescribed
by a physicianas a standard treatment option for participants with opioid
addictions.
Introduction
This report does not suggest that MAT is appropriate for every opioidaddicted individual. It does recommend, however, that courts make decisions
about MAT individually, based on objective medical evidence.
A Close Look at 10 Courts

The Legal Action Center, working closely with the Office of Court Administration
and the Center for Court Innovation, produced this report based on in-depth
interviews with 10 New York State drug courts, site visits to three of those
courts, and a review of existing research.
The authors chose these 10 courts because they permit participants to use
all three FDA-approved medications for opioid addiction and do not require
individuals to stop taking their medications against medical advice. They
also represent a cross section of courts based on geography and size. After
interviewing these 10 courts, the authors selected three for in-depth profiles.
The three reflect different regions from around New York, including urban,
suburban and rural communities. They also reflect a variety of participant
demographics, sizes, resources, and availability of different types of addiction
medication.
Section I of this report provides an overview of medication-assisted
treatment, including recent scientific research. It describes the medications
and how they work, and addresses some common questions and concerns
about MAT. Section II describes nine components of effective drug treatment
program, as gleaned from interviews and site visits with drug courts around the
state.
Section III offers in-depth profiles of three courts. The selected courts provide
a range of perspectives and practices regarding the use of MAT. The courts are
not named or specifically identified. However, readers interested in speaking
with representatives of the profiled courts can contact the Office of Court
Administration at ProblemSolving@nycourts.gov.
Section IV discusses special issues rural courts may encounter. Finally, the
Appendices contain additional information about MAT, including a chart
comparing MAT medications (Appendix A), myths and facts (Appendix C), an
article about MAT (Appendix D), and a list of further resources (Appendix E).
I. Medication
Assisted
Treatment
What is Medication-Assisted Treatment?

Medication-assisted treatment is the use of medications in combination
with counseling and behavioral therapies for the treatment of substance use
disorders, including opioid addiction.6 MAT operates to normalize brain
chemistry, block the euphoric effects of opioids, relieve physiological cravings,
and stabilize body functions without the negative effects of the short-acting
drugs of abuse.
Three medications are currently approved by the FDA to treat addiction to
short-acting opioids, such as heroin, morphine, and codeine, as well as synthetic
opioids, including oxycodone, OxyContin, and hydrocodone. The three are
methadone, buprenorphine/naloxone (Suboxone, which for purposes of this
report is referred to as buprenorphine), and long-acting injectable naltrexone
(with the brand name of Vivitrol). A chart with information about the three
medications is in Appendix A.
Methadone
Methadone is an agonist that works by reducing or extinguishing cravings
for opioids, allowing the patient to function without the major physiological
components of opioid disorder.7 When used as an addiction medication,
methadone can only be dispensed in an opioid treatment program. Opioid
treatment programs are any treatment program certified by the Substance
Abuse and Mental Health Services Administration (SAMHSA) in conformance
with 42 Code of Federal Regulations (C.F.R.), Part 8, to provide supervised
assessment and medication-assisted treatment for patients who are opioid
addicted. An opioid treatment program can exist in a number of levels of care
and settings, including, but not limited to, intensive outpatient, residential, and
hospital settings. When used as an addiction medication, methadone is typically
given in liquid form as a daily dose taken under observation.
Buprenorphine
Buprenorphine is a partial agonist which functions similarly to methadone but
has a lower maximal effect than a full agonist like methadone. Maintenance
on methadone or buprenorphine produces no euphoria, intoxication, or
withdrawal symptoms. Buprenorphine is almost always combined with

naloxone to deter abuse; the naloxone induces withdrawal symptoms if the
medication is misused by being injected. Buprenorphine combined with
naloxone is sold under the brand name Suboxone. Buprenorphine can also be
dispensed in an opioid treatment program, or it can be provided by a physician
who meets established qualifications to provide office-based treatment for
opioid addiction.
Individuals typically take buprenorphine at home in the form of a sublingual
film, often referred to as a strip. Currently, federal regulations limit the
number of patients a physician can treat with buprenorphine at one time: 30
patients the first year, and 100 patients in subsequent years. In September 2015,
SAMHSA announced that it would be changing the regulations to expand the
availability of treatment with buprenorphine.
Naltrexone
Naltrexone is an opioid antagonist which operates by blocking the effects
of opioids so patients will not experience a high from using opioids. People
who are dependent on opioids must stop their drug use at least seven days
prior to starting naltrexone. Naltrexone to treat opioid dependence is usually
delivered in the form of a monthly injection by a physician. Individuals can
receive naltrexone in many settings, including doctors offices, opioid treatment
programs, and other drug treatment settings.
Is MAT effective?
Dozens of studies have shown that medication-assisted treatment reduces
drug use, disease rates, overdose deaths, and criminal activity among opioid
addicted persons.8 According to the National Institutes of Health, The safety
and efficacy of narcotic agonist (methadone) maintenance treatment has
been unequivocally established. Research demonstrates that MAT patients
experience dramatic improvements while in treatment and for several years
following, including decreases in narcotic use, drug dealing, and other criminal
behavior as well as increases in marriage and employment.9 One study found
a 50 percent reduction in fatal overdoses among people receiving methadone
or buprenorphine as part of their treatment.10 Another showed a 75 percent

decrease in illicit opioid use among those receiving buprenorphine and
counseling for one year, compared with those who received buprenorphine for
only six days, followed by counseling.11
MATs critical benefits for people involved in the criminal justice system are
also well established. Drug overdose is the leading cause of death for individuals
reentering society after incarceration.12 Numerous studies show MAT reduces
drug overdose deaths, recidivism, and infectious disease among criminal
justice involved persons.13 For example, one study showed that people receiving
methadone maintenance treatment with counseling in a Baltimore prison and
continuing it upon release reported half the rate of illicit opioid use compared
to those who received only counseling.14 They also were almost three times less
likely to spend time in jail or prison.15 Another study showed that the use of
injectable naltrexone in a New York City jail decreased illicit opioid use by more
than 50 percent following release.16
Does MAT substitute one drug for another?

Though two of the three MAT medications (methadone and buprenorphine) are
opioid-based, they are fundamentally different from short-acting opioids such
as heroin and prescription painkillers. The latter travel directly to the brain and
narcotize the individual, causing sedation and the euphoria known as a high.
In contrast, methadone and buprenorphine, when properly prescribed and
utilized, reduce drug cravings and prevent relapse without causing a high.17
They help patients disengage from drug seeking and related criminal behavior
and become more receptive to behavioral treatments.18 Injectable naltrexone is
not opioid based and does not result in physical dependence.19
How is the appropriate dose determined?

For methadone and buprenorphine, a certified health care professional
determines the appropriate dose, in consultation with the patient, and
calibrates the dose to the individuals medical and physiological needs. Once
individuals are stabilized on the appropriate dose, they may be maintained
on that dose for as long as medically necessary, as is the case with other
10
medications for chronic health conditions. For injectable naltrexone, the dose is
standard and generally is delivered every four weeks.20
People unfamiliar with the science of MAT sometimes question why an
individual is taking what they perceive as a high dose of methadone or
buprenorphine. Dosing, however, is an individualized medical decision. For
example, most patients require a methadone dose of 60-120 milligrams per
day; studies show that patients on higher doses stay in treatment longer and
use less heroin and other drugs than those on lower doses.21 Pre-conceived
beliefs, without scientific basis, that lower doses are preferable, detract from the
potential value of MAT.22
How long should someone receive MAT?

There is no one-size-fits-all duration for MAT. The Substance Abuse and Mental
Health Services Administration recommends a phased approach, beginning
with stabilization (withdrawal management, assessment, medication induction,
and psychosocial counseling), and moving to a middle phase that emphasizes
medication maintenance and deeper work in counseling. The third phase is
ongoing rehabilitation, when the patient and provider can choose to taper
off medication or pursue longer term maintenance, depending on the patients
needs.23 For some patients, MAT could be indefinite.24 The National Institute
on Drug Abuse (NIDA) describes addiction medications as an essential
component of an ongoing treatment plan to enable individuals to take control
of their health and their lives.25 For methadone maintenance, twelve months of
treatment is the minimum, according to NIDA.26
Long-term medication may be beneficial. Dr. Nora Volkow, Director of NIDA,
explains:
Medications can be helpful in [the] detoxification stage, easing
craving and other physical symptoms that can often trigger a
relapse episode. However, this is just the first step in treatment.
Medications have also become an essential component of an
ongoing treatment plan, enabling opioid-addicted persons to
regain control of their health and their lives.27
Are there risks to requiring someone to taper from MAT?

Requiring people to stop taking their addiction medications before their
provider recommends it is counter-productive and increases the risk
of relapse.28 Furthermore, because tolerance to opioids fades rapidly, one
episode of opioid misuse after full withdrawal can result in life-threatening
or deadly overdose.29
How much does MAT cost, and is it covered by Medicaid

and other insurance?
MAT medications and treatment vary significantly in price, depending on the
medication, setting, other services provided, and availability of discounts, such
as a sliding scale. Methadone generally costs about $80 per week, for medication and all other services, but many opioid treatment programs provide a sliding scale. Buprenorphine and naltrexone cost more, but prices also vary greatly.
New Yorks Medicaid program fully covers all three MAT medications. Naltrexone has not been as widely available as the other two medications, largely due
to the higher price and reimbursement mechanism for injectable naltrexone.
But with the roll out of Medicaid managed care for substance use treatment in
New York, reimbursement mechanisms are changing. Until recently, New Yorks
Medicaid plan required physicians to buy naltrexone upfront and then seek
reimbursement, which had the effect of limiting the medications availability.
With changing rules under Medicaid managed care, physicians may find it more
financially viable to prescribe naltrexone.
Most private insurance plans in New York also cover all three MAT
medications, but some impose limits, such as on the duration of use. Some
private plans also require physicians to buy naltrexone and then seek
reimbursement, but with the Medicaid shift described above, many private
plans may follow suit because they operate both private and Medicaid plans.
Where can I get more information?

Much of the information in this section is based on the Myths and Facts Sheet in
Appendix C. Appendix E lists additional resources.
11
12
II. Nine
Components
of Successful
MAT Programs
12
Nine Components of Successful MAT Programs

Interviews with ten drug courts throughout New York revealed these key features of effective MAT programs.
1. Counseling and other servicesplus medication

are essential.
Courts require medication-assisted treatment participants to receive counseling
and wraparound services from a licensed treatment provider in addition to
medication. These services are no different from those provided to participants
not receiving MAT.
2. Courts are selective about treatment programs and

private prescribing physicians.
In New York, courts require participants to obtain an assessment at one or more
designated licensed treatment programs. When MAT is recommended, the
courts generally prefer that MAT medication and other services be provided by
a program licensed by the New York State Office of Alcoholism and Substance
Abuse Services, usually on a court-provided list. However, participants
receiving buprenorphine sometimes receive the medication from an officebased physician, most commonly if the licensed treatment programs have
reached their federally mandated buprenorphine cap (currently 30 patients the
first year; 100 patients annually, thereafter). Courts also permit participants
to receive injectable naltrexone from private doctors because they inject the
medication monthly, which addresses concerns about diversion. With all forms
of MAT, participants still must receive counseling and other services from a
licensed treatment program. If a court finds that a provider does not meet the
courts standards, it typically does not permit future participants to use
that provider.
3. Courts develop strong relationships with treatment

programs and require regular communication
regarding participant progress.
Trust and communication are essential. Courts with successful MAT programs
13
14
maintain frequent contact with treatment providers. They expect honest and
accurate reports, as well as follow-through. If providers do not communicate
sufficiently, courts stop referring participants and select other providers. The
consensus among the 10 courts interviewed is that licensed treatment programs
generally are more reliable communicators than private physicians.
4. Screening and assessment must consider all clinically

appropriate forms of treatment.
Court staff conducts the initial screening and refers to programs who conduct
a complete assessment. Clinical staff within the court and in partner treatment
programs used as referrals must be open to all clinically appropriate modalities,
including MAT. In New York, the Office of Alcoholism and Substance Abuse
Services recent release of the LOCADTR 3 tool for determining level of care will
facilitate the use of evidence-based treatment.30
5. Judges rely heavily on the clinical judgment of

treatment providers as well as the courts own clinical
staff.
Judges understand that treatment professionals have the expertise to make
treatment decisions, that such decisions should be evidence based, and that
courts should not withhold appropriate medical treatment as a sanction.
Practices vary as to the amount of input court clinical staff have with outside
treatment providers. Some court staff share their views more actively with
providers while others defer to the providers judgement.
6. Endorsement of medication-assisted treatment by all

members of the drug court team is the goal, but not a
prerequisite.
All courts agreed that the program works best when all members of the drug
court team support MAT. Indeed, those courts that had buy-in from the whole
team evinced a more positive view of their own programs. But even in courts
where key players (e.g., a judge or district attorney) have reservations about
addiction medication, MAT programs can succeed as long as the team views
clinical decisions as the province of clinicians. Education about MAT, whether

provided by the state or other sources, is critical in getting all team members on
the same page about MAT. For some courts, the decision to allow MAT resulted
from active discussion among drug court team members. In other courts, team
members responsible for treatment recommendations simply started using it
without much fanfare. Those team members who had resisted MAT acclimated,
as the inclusion of MAT generally turned out to be relatively simple and
occurred without significant changes to court practice.
7. Monitoring for illicit use of medication-assisted

treatment medication is a key component of the
program and can be accomplished in different ways.
Courts use a range of methods, such as urine tests, pill/strip counting, and
behavioral observations to detect misuse or abuse of medication. These
methods generally are not that different from those used to monitor illicit drug
use by other non-MAT participants. Some courts do more of the monitoring
themselves, while others may rely primarily on treatment programs with which
they communicate regularly.
The method and extent of monitoring also depend on the type of medication.
Buprenorphine patients typically take home a months worth of medication,
which requires more vigilant monitoring. Methadone patients, on the other
hand, typically take their dose under observation by the provider (in liquid
doses at the clinic) so cannot misuse their medication as easily. Naltrexone is
generally injected by a physician, and therefore, viewed as the least divertible
medication. All courts acknowledge that there is some illicit diversion of MAT
medication (mainly buprenorphine), but see it as something that they can
manage and that does not justify a blanket prohibition. Many practitioners note
that illicit use of medication occurs among opioid addicted people who are not
enrolled in MAT programs and who often use MAT medication illicitly to selfmedicate; such misuse might decrease with more access to MAT.
15
16
8. Medications for medication-assisted treatment are

covered through government and/or private insurance
programs.
Medicaid or other insurance programs generally pay for participants treatment,
especially in the initial stages of drug treatment court. When participants begin
working, coverage can become more challenging. Courts try to help participants
access appropriate coverage, but are not always successful. For those who
need to self-pay, methadone is much less expensive than buprenorphine and
naltrexone.
9. Medication-assisted treatment operates very similarly

to other kinds of treatment.
Courts repeatedly emphasized that they did not do things very differently for
MAT participants. Some courts conduct identical urine testing for MAT and
other participants, while other courts add methadone and buprenorphine tests
for MAT participants only. A few courts also count buprenorphine strips. Thus,
many of the key components noted above are also essential for other parts of the
treatment courts operation.
Introduction
III. Court
Profiles
17
18
Central New York Treatment Court

Jurisdiction: Mid-size city and nearby suburban and rural areas
Overview
This court has been operating since 1997 in a county with a population of
about 500,000. The county includes a mid-sized city, its suburbs, and rural
areas. The courts docket averages 250 cases. In addition to the judge, the
court has a staff of six: project director, resource coordinator, and four case
managers. Other members of the drug court team include a probation officer,
prosecutor, assigned counsel, and representatives from treatment programs
and a vocational rehabilitation program. Eligible offenses include both drug and
non-drug, non-violent felony and misdemeanor offenses that can be processed
either before or after a guilty plea. Upon successful completion of misdemeanor
cases, charges are dismissed and sealed. For felony cases, the court takes a
misdemeanor plea and sentences the offender to a conditional discharge.
About 70 percent of the courts participants have an opioid addiction, and
nearly all of them receive MAT. In 2015, about 74 percent of participants
were white, non-Latino/a; about 20 percent were African-American; roughly
three percent were Latino/a; and less than one percent were other races and
ethnicities. About two-thirds were male and one-third were female.
Which opioid treatment does the court use?

The court permits participants to receive all current MAT medications and
requires all participants to receive counseling and other supportive services
from a state-licensed treatment program. The court does not permit any
participants to receive addiction medication without these additional services.
The court maintains a list of approved providers, based on criteria such
as effective communication, monitoring, and follow-through. The court has
excellent relationships with providers on this lista vital element to the
programs success. The court, not the participants, chooses the MAT treatment
provider, as it does for other forms of treatment. The type of MAT participants
use breaks down as follows:
III. Court Profiles
Methadone: Currently, only a few participants receive methadone

maintenance treatment because the county has only one opioid treatment
program with typical waiting lists of several months.
Buprenorphine: Nearly all participants currently receive buprenorphine
because it is the most available. The courts list of approved providers evolves
based on the courts experiences with individual providers. For example,
providers who communicate effectively and cooperate with the court remain on
the list; those who do not are removed. All participants receive the medication
at outpatient programs designated by the court. Those who live in a half-way
house give the medication to the manager, who distributes it at a set time. A
small number receive it through office-based physicians on the court-approved
list (which excludes physicians who accept cash only), but only if the outpatient
program treating the client has reached its buprenorphine cap (100 patients
per doctor). Any such participant must attend the outpatient program for
counseling and other services.
Naltrexone: Very few participants receive naltrexone because most treatment
programs do not offer it, and there is limited availability among private
physicians. (Read more in Section I).
Who makes treatment decisions?

Members of the drug court
team are united in their view
Im not a treatment provider or
that clinical staff should make
doctor. How can I say you dont
treatment decisions. As the
need MAT?
prosecutor says, Im not a
Prosecutor
treatment provider or doctor.
How can I say you dont need
MAT? Case managers say they
guide the participants, but
treatment programs lead.
Prospective drug treatment court participants receive a substance use
disorder assessment and psychosocial evaluation by a credentialed case
manager, who uses a standard assessment tool. The court then refers individuals
19
20
to a state-licensed treatment program for a more in-depth assessment.

Most prospective participants are not receiving MAT or any other treatment
at the time they enter drug treatment court, but many express a desire to enroll
in MAT. Some individuals really believe they need something or they will use,
according to the probation officer assigned to the court. The courts clinical staff
sometimes provides input about whether a participant should receive MAT, and
expects to collaborate with the treatment providers to agree on an appropriate
treatment plan.
Many individuals entering drug court report prior use of buprenorphine or
methadone. Some have used MAT in treatment programs and some admit to
prior illicit use (mainly of buprenorphine). Some participants admit to diverting
their medication. While the court does not condone illicit use, neither does it
deny access to buprenorphine through a licensed treatment program solely
because of prior illicit use. The court works to get participants a legitimate
prescription to aid in recovery.
What services does the court require in addition to MAT

medication?
The court requires all MAT participants to receive counseling and the full array
of other services provided by the court and community-based programs. For
example, the courts case managers help participants access mental health
and medical care, housing, child care, employment, and obtain essential
documents, such as birth certificates and social security numbers. All of the
programs provide individual and group counseling, physical and psychological
examinations and evaluation, and other supportive services.
Drug court team members and treatment providers all emphasize that
MAT is more than medication. Counseling is criticaland requiredthough
the frequency generally decreases as the patient progresses in treatment.
The court uses the same approach for participants not receiving medication.
The probation officer notes the complementary nature of medication and
counseling: Participants generally need medication to address the physical
dependence. With medication, they do not need to think about using all day long
and can focus on their recovery.
III. Court Profiles
How long do participants stay on medication-assisted

treatment? Who decides?
As with other treatment decisions, the physician and treatment provider, in
consultation with the patient, make decisions about duration of MAT. The court
does not require or encourage people to titrate down. Some individuals want to
taper and stop MAT ultimately, but the court encourages them to discuss these
issues with their treatment provider.
The court sees some advantages to a longer course of MAT. Prolonged
treatment with medication means the patient will have regular contact with
a physician, which the court views as a plus. Even if they graduate, the
prescribing doctor still needs to see them. The longer participants see someone,
the better chance they have of staying out of the system, says the courts
program director. The prosecutor is hesitant to recommend that anyone taper
off their medication because she has observed people relapsing while tapering
off their recommended dose.
How does the court monitor compliance and illicit use of

medication?
The courts strategies to monitor and encourage compliance are similar to those
used for all drug court participants. Monitoring MAT participants does not
require substantial extra work or expense.
Treatment programs do the lions share of monitoring and are in regular
communication with the court. When participants complete the counseling
portion of their treatment, monitoring shifts more to the court. Key components
of monitoring include the following:
1. Close monitoring of MAT medications.
Court team members agree that buprenorphine has the greatest potential for
misuse because patients take it home. Methadone is rarely diverted illicitly
because it is dispensed daily in liquid form (with limited take home privileges)
and clinic staff directly observes ingestion. Most methadone sold on the streets
is the pill form, prescribed for pain. Naltrexone cannot be abused. It is
21
22
an antagonist medication, not an opioid, and typically is injected monthly by

a physician.
Following are the courts strategies to prevent and monitor illicit use of MAT
medication or drugs generally. Each strategy complements the other; none is
used in isolation:
a. Urine testing
Who tests and how? Treatment programs do most of the urine testing in
the earlier stages of participation, and the court takes on a greater role after
participants complete treatment, but are still enrolled in drug court. The
probation officer also conducts weekly testing for participants on probation.
The court conducts random testing during court appearances, as well as by
assigning colors and calling individuals with certain colors to come in
for testing.
Does anyone test for levels of MAT medication? None of the court, probation,
or treatment programs tests for the specific level of MAT medication (i.e., to
ensure that participants are taking their full dose, rather than diverting it), and
such tests may not be reliable. Moreover, they do not view that level of testing
as necessary. They believe that other methods, such as urine testing and
those described below, sufficiently address illicit use.
b. Pill and strip counting.
Who counts and how? If there is suspected misuse, the court counts
buprenorphine pills and strips. For those participants under probation
supervision, the probation officer counts pills and strips only for participants
not living in halfway houses. (Halfway houses keep the buprenorphine strips
securely stored and distribute it daily.) Program practices vary, with some
engaging in regular random counting and others only counting if they
suspect misuse.
III. Court Profiles
What if participants sell and buy strips? Each buprenorphine strip has a
number. Some programs photocopy the strips before distributing them to
patients and then match the returned strips with the copies.
Is pill and strip counting a burden? None of the drug court team members
considered it time consuming or otherwise onerous.
c. I-STOPprescription drug monitoring program.
Checking I-STOP, New Yorks prescription drug monitoring program, is another
tool to detect illicit use of buprenorphine. I-STOP is a program established by
the New York State Department of Health, requiring prescribers/dispensers
of Schedule II, III, and IV controlled substances to check an online registry
for such prescriptions over the past six months. One participants treatment
program checked I-STOP and learned that the patient had obtained
buprenorphine from a physician in New York City while also receiving it from
the central New York prescriber.
d. Observation.
Court personnel, probation, and treatment programs all observe participants
behavior and appearance. Are participants appearing for court and
probation appointments? How do they look and feel? Do they appear high?
Appearance alone would not be the basis for a sanction, but it might trigger
an investigation. Similarly, physicians who observe positive urines or missed
groups investigate for illicit use or diversion of medication. One program
physician commented that by developing strong therapeutic relationships
with patients, he generally can detect when they are not truthful.
The judge relies mainly on reports from treatment programs but also makes
his own observations and listen to participants. Does the participant seem
to be truthful? Does s/he report the same information to the judge, case
manager, and treatment counselor? Or do explanations continually change?
2.
Excellent communication with treatment programs.
All members of the drug court team cite the excellent communication with
23
24
programs as a major reason for the success of the MAT program and the drug
treatment court generally. Communication aids in monitoring medication use
(and misuse) and progress in treatment generally, while also enabling the players
to address issues as they arise. Highlights of the courts communication with
treatment providers are as follows:
a. Use of multiple forms of communication.
Programs and the drug court team communicate through email, phone calls,
and meetings in court (program staff sometimes attend court staff meetings),
in addition to formal weekly written reports. Treatment programs assign one
staff member to appear at every court date in case the court has questions.
b. Communication early and often with a problem-solving approach.
Programs generally notify the court as problems arise so they can be
addressed. They call us right away, notes a case manager. The judge explains
that sometimes a treatment program notifies the court about a problem that
the program is addressing but does not yet want discussed in court. The judge
honors that request, but is glad to know about the issue. Communication
is not limited to objective data, such as attendance and urine screens,
but includes discussion of behavior and other issues that court staff and
treatment professionals can address jointly.
Communication is not always flawless. Some court staff report occasional
frustration with programs not returning calls in a timely manner and not
providing information upfront. In some instances, the court has discontinued
making referrals to programs because of poor communication. However,
generally, the quality of communication was deemed excellent.
How does the court respond to non-compliance and

relapse?
The court uses a variety of tools to address non-compliance. Responses include
increased counseling and services, a higher level of treatment, more court visits,
warnings, and jail time. The judge places a high value on honesty and effort.
Therefore, individuals who lie and fail to appear at appointments are likely
III. Court Profiles
to receive a harsher sanction than those who are forthcoming about relapse,
especially early in treatment. The court, however, does not order people to
discontinue MAT if they
relapse. The court relies heavily
on the treatment programs
What resources does a drug
recommendation concerning
court need to incorporate MAT?
continued use of MAT.
According to one case manager,
just a phone, a treatment provider,
What are the
and a doctor. Invite these people
consequences for sale
into a room for a meeting. Its not
of MAT medications?
that difficult.
Participants who sell their
MAT medication receive an
immediate sanction of jail time, which is the same sanction received by nonMAT participants who sell drugs illegally. Any decision about the individuals
continued participation in MAT is made in consultation with the physician and/
or treatment program.
Is illicit diversion of MAT medications common?

No. Drug treatment court team members say that most participants truly want
to succeed and do not divert their medication. Most participants are so grateful
to get Suboxone that they dont want to mess it up, explains one team member.
A treatment provider notes that patients value their medication more than
some people think. People tend to focus on those who are not doing well as
opposed to those who are.
At the same time, drug court team members know that some illegal diversion
of MAT medication (mainly buprenorphine) occurs despite their best efforts to
prevent it. Ultimately, there is no way to stop illegal use and diversion entirely.
Yet they believe the pros of using MAT far outweigh the cons of some diversion.
The prosecutor sums it up this way: MAT is definitely successful. Suboxone will
end up on the street [whether or not the court permits it]. But you will have
more success in your community if you allow all the tools that work.
25
26
Does allowing medication-assisted treatment create a

burden and cost for the court?
The general feeling within the drug court team is that incorporating MAT is not
a burden. The only additional cost is the minimal expenditure for the drug tests
that identify buprenorphine and methadone. What resources does a drug court
need to incorporate MAT? According to one case manager, just a phone, a
treatment provider, and a doctor. Invite these people into a room for a meeting.
Its not that difficult.
The probation officer finds that supervising individuals on MAT is no more
challenging than supervising anyone else. If anything, they are more compliant
because they have a doctor and counseling.
Who pays for medication-assisted treatment?

Most participants cover MAT costs through Medicaid, which, in New York,
covers methadone, buprenorphine, and naltrexone. A small number have
private insurance. When participants transition to employment, the courts
case managers help them obtain new coverage if they do not retain Medicaid
eligibility. Some do retain Medicaid because they earn below the threshold.
Others access insurance through the New York State Exchange, though some
cannot afford the subsidized premiums. Some obtain insurance through their
employers or family members. Those who cannot afford or access any form of
insurance try to self-pay, but also get assistance from a variety of sources. For
example, pharmaceutical companies provide coupons, and the opioid treatment
program has a sliding scale. There is also a generic version of buprenorphine
that brings down the price.
What challenges does medication-assisted treatment

pose?
Drug court team members do not view any challenge as unsurmountable, but
some challenges other than those already noted include:
Insufficient treatment capacity for all three MAT medications, which can
lead to heavy reliance on buprenorphine (though it, too, is limited). For
III. Court Profiles
more information, read the discussion in Section I about the availability

and cost of MAT.
Lack of family support. Some participants face resistance and stigma
from family members, generally due to a lack of information about MAT.
To overcome this challenge, case managers do their best to educate
family members. Sometimes they do not succeed until the participant has
relapsed without MAT.
Stigma against MAT at many 12-step programs. Clients can face hostility
to MAT at 12-step meetings and consequently may choose not to disclose
their MAT participation. To address this challenge, case managers provide
information about 12-step meetings with a reputation for more openness
to MAT. They report that this problem has diminished over time.
Limited MAT at the local jail. When serving a jail sanction, individuals
can receive methadone, but not buprenorphine or naltrexone. Moreover,
no MAT is available for people who are sentenced, except for pregnant
women. Individuals on methadone at the time of sentencing must titrate
down. If people are sentenced while on buprenorphine or naltrexone, jail
staff treats them for withdrawal.
How did this courts MAT program begin?

The court incorporated MAT during its inception in 1997. The judge and
coordinator were both in favor of providing access to methadone maintenance
treatment, and there was no opposition by other key players. As each new MAT
medication has been developed, the court has incorporated it to the extent
that it is available. The court works to educate its staff and other drug court
team members through trainings offered by the state licensing authority and
court system.
How do court personnel view medication-assisted

treatment?
While no one has formally studied the effects of MAT on participants success,
the overwhelming sentiment of drug court team members is that MAT is a
highly effective component of their court and is crucial in addressing the opioid
27
28
epidemic. Not using MAT is

like repairing a car without
Not using MAT is like repairing
a wrench, says the judge.
a car without a wrench, says the
Courts need to use all available
judge.
tools to treat opioid addiction.
The program is great,
according to the probation
officer. Several clients were successful on MAT and would not have been
otherwise. Case managers deem it absolutely successful. In their day-to-day
experience, they see behavioral differences between participants who are and
are not in MAT. They find that participants who are in MAT tend to be more
goal-oriented and stick to their plans; the court can retain them. Staff has seen
participants succeed without MAT, but think that most do not. In most cases,
participants who do not use MAT continue to use opioids illegally, do not appear
for treatment and court dates, buy buprenorphine on the street, and then detox
in jail.
III. Court Profiles
Upstate Treatment Court

Jurisdiction: Small city and the surrounding suburban and rural areas.
Overview
This small court serves a county with a population of about 160,000. Though
the court is located in the city, many of its participants live in the surrounding
rural and suburban areas. It has operated since the mid-1990s. The court has
a docket of approximately 25 participants. Its full-time staff consists of one
resource coordinator, but it has support from a large team which meets every
two weeks. Members of the drug treatment court team include the judge, the
court clerk, the substance use counselor from the Department of Social Services,
and representatives from the District Attorneys Office, Public Defenders Office,
probation, and the local jail.
Eligible offenses include misdemeanors, except domestic violence with
intimate partners, sex offenses, arson, or violent offenses. Court participants
have entered pleas with their sentences deferred until program completion.
Upon successful completion of drug court, their pleas are almost always
withdrawn and reduced to a six-month adjournment in contemplation of
dismissal.
Approximately 75 percent of participants have an opioid addiction, and about
half of those receive MAT. Between a third and a half of the participants who
receive MAT have had previous experience with it. The court does not capture
demographic information about participants but estimates that most are
Caucasian, about 10 percent are African-American, and 5 percent are Latino/a.
The percentage of men and women fluctuates.
Which Opioid Treatment Does the Court Use?

The court permits participants to receive any of the available addiction
medications while also receiving counseling and other services from a statelicensed treatment program. The court does not permit any participant to
receive addiction medication without these additional services.
Based on the level of care determination, the resource coordinator usually
gives participants a list of programs that can provide the appropriate treatment
29
30
modality and lets participants select the program they think will work best
based on schedule, location, or other needs.
The court does not make recommendations about MAT. If participants tell
the resource coordinator that they are interested in MAT, she tells them to talk
to the treatment program about it at their assessment. The selected treatment
program determines whether someone will receive MAT based on its more
detailed assessment. Prior misuse of an addiction medication does not prevent
someone from accessing medication to support treatment. Almost all of the
participants with opioid addiction have at some point misused buprenorphine,
but when they receive it as medication with proper monitoring, the court finds
they are unlikely to misuse it.
The type of MAT participants receive breaks down as follows:
Methadone: Currently, only two pregnant participants receive methadone
maintenance treatment. There are only two methadone programs within a 200mile radius, making access difficult. In addition, participants in methadone
maintenance face particularly strong stigma in the community.
Buprenorphine: Nearly all participants on MAT receive buprenorphine
because it is the most available. About 85 percent receive it from their treatment
programs. The few participants who receive buprenorphine from private
doctors already were being treated by them before they came into drug court, or
attend the local treatment program that does not provide MAT. If a participant
needs to find a private doctor, the treatment court provides them with a list of
approved doctors. If doctors do not use appropriate clinical standards (e.g.,
do not examine patients or conduct drug testing), the court does not allow
participants to use them.
Naltrexone: No participants currently receive naltrexone because of its high
price and insufficient insurance coverage. The court expects to increase use
of naltrexone as changes in pricing and insurance coverage make access more
feasible.
III. Court Profiles
Who makes treatment decisions?

The court staff expects the treatment programs to make treatment decisions
while taking into consideration the courts input. The resource coordinator
reports good relationships with the local programs and thinks they see her as
a support. She is able to share information with them and says the programs
end up on the same page. Usually, when we put our heads together, we find
better solutions.
At intake, the resource
coordinator conducts the
The court monitors MAT
standard substance use disorder
participants with the same
screening and psychosocial
strategies used for other
evaluation to determine the
participants, with the single addition
level of care, sometimes in
of counting the buprenorphine
consultation with the substance
strips.
abuse specialist for the
countys Department of Social
Services. The resource coordinator then refers participants to a state-licensed
treatment program for more detailed assessments and a treatment plan with
the expectation that the program will discuss its treatment plan with her. She
is almost always comfortable with the plan, but if she has concerns, she raises
them, as she does if issues arise during treatment.
The resource coordinator finds that programs and doctors are very
responsive to her concerns. I have collateral information that they dont
have. We compare notes. When I interview people in jail they tend to be more
forthcoming, she says. In one case, a participant told her about drug use that he
did not report to the program. Another time, the coordinator contacted a doctor
to let him know that when prescribed 30 mg. of buprenorphine, the participant
was nodding off in court. The doctor decided to lower the dose. The coordinator
cannot think of a time when she and the program have not been able to agree
about a plan.
The resource coordinator can also be a support for the programs because
she is familiar with the other agencies in the area. For example, a residential
program needed to release a court participant to supportive living. The
31
32
residential program identified two possibilities, unaware of significant problems

at both programs. The resource coordinator was able to identify an alternate
provider that was better run and could more effectively serve the participant.

medication?
Every participant must receive counseling whether or not they receive MAT.
MAT participants are not treated any differently from other participants, the
resource coordinator reports. Participants treatment programs also may refer
them for additional services, including vocational counseling, mental health
treatment, and trauma counseling, as needed. All participantsMAT recipients
and othersreceive these wraparound services.
Drug court team members convey that incorporating addiction medication
does not otherwise change their approach to treatment. The judge explains,
MAT is just one part of a multi-faceted approach to maintain sobriety. He
adds, MAT is not a panacea. Its not like you can pop a pill and addiction is
going to be resolved You try outpatient. Is this working? Try five days instead
of three days a week. Not working? Residential. You have to try various things.
You have to be open to every tool that is out there.

MAT medication?
The court monitors MAT participants with the same strategies used for other
participants, with the single addition of counting the buprenorphine strips. As
the assigned prosecutor says, monitoring may be a challenge, but we have to
monitor even if participants are not on medication. The court does not feel it
can rely solely on programs and doctors to thoroughly monitor participants,
whether or not the participants receive MAT. Accordingly, the court develops its
own protocols for monitoring compliance.
The courts monitoring protocols include the following for all participants:
1. Urine Testing
Who tests and how? The court conducts its own random testing of all
III. Court Profiles
participants at least weekly. Participants are required to call the court every
weekday to find out if they need to report for random testing. The court
does not rely on the programs to test because some of them seem to test on
predictable days, for example, every Monday, do unobserved tests, or do not
test frequently enough.
Frequency? The drug court team emphasizes the importance of testing at
least weekly, sometimes more, and making sure the schedule is unpredictable.
For example, the court sometimes tests someone two days in a row or even
twice in one day by testing in court and then calling the program and asking
them to test when the person returns. They also continue frequent testing
even in the last phase of court supervision because they are concerned that
people may slip as their treatment requirements decrease.
Extra testing for medication? All participants are tested for buprenorphine and
methadone whether or not they receive MAT. The court wants all participants
to understand that they will be tested for these medications and that the court
knows how to interpret the test results. Participants know they will not be able
to falsely claim that a positive test result for another illicit substance is the
result of their prescription medication.
2. Parental involvement for young people
When participants under 25 years old live with their parents, the court requires
that they sign a release for the court to communicate with their parents. The
court then may check in with the parents about how the young person is
doing at home.
3. Observation
Court personnel observe participants in court and follow up with participants
who are not behaving like themselves. For example, if they are flying off the
handle, acting jumpy, or using the bathroom five or six times during court,
court staff will intensify supervision. They also find that other participants
have a better sense than staff of when someone is struggling. Observing how
33
34
other participants look at a peer may give an indication that court staff should
follow up with the person.
The court coordinator believes that by getting to know participants, she can
more effectively identify potential issues. Court participants mentioned that it
is helpful to know that the court coordinator is there to talk to and that she
is open-minded to maintenance treatment. The coordinator also comments
that one benefit of doing so much testing is that it is an opportunity to see
the participants out of court when there is more time to talk. Observed urine
testing can be an uncomfortable situation for some participants, so Ive
learned to start chatting with them. You can get a different kind of information
when youre in this situation, the court coordinator says.
4. Communication with treatment
providers
The court coordinator could not
Communication with the
think of an instance in which the
treatment providers sometimes
court learned a participant was
requires persistence. The
selling medication.
resource coordinator ensures
that the court ultimately gets the
information it needs, but it can require a lot of her time; it can be especially
hard to stay in touch with independent doctors.
Frequency: The court usually expects weekly reports from treatment
programs, though the frequency depends on the participants progress. When
someone is struggling, the court may talk to the program multiple times in a
day; if someone is doing well, it may accept reports biweekly. The court does
not expect reports from independent doctors who are not connected with
programs, but the coordinator calls them if an issue arises.
Method: Communication is usually by email, but some providers prefer not to
communicate in writing, in which case the resource coordinator calls them.
III. Court Profiles
Communication challenges: The court has encountered programs or private

doctors who are hard to reach or who do not report accurately or with
enough detail. For example, a program may report that everything is fine and
later report that they are discharging the participant for reasons that show
the original information was inaccurate. Doctors can be especially difficult
to reach, sometimes even when they work in connection with a treatment
program, but especially when they are solo practitioners.
Responses to communication problems: When there has been a lapse in
communication with the program, ccing the programs clinical directoror in
the case of a methadone program, the medical directorusually produces a
response. If an independent practitioner is unresponsive, the court tells the
participant that they need to help encourage their provider to respond, or they
may not be able to continue to see that provider.
In New York, in the unusual situation that the court has extreme concerns
about a provider, the court files a complaint with the Office of Alcoholism and
Substance Abuse Services through the agencys liaison at the Office of Court
Administration.
5. Strip counting (for MAT participants only).
In addition to the above monitoring protocols, participants who receive MAT
are monitored with strip counting. The court expects programs to count
the buprenorphine strips of participants who receive this medication. When
participants live in community residences, they must provide their strips to
the staff, which makes strip counting easy. The court also does some strip
counting itself if a program does not follow strict protocols.

relapse?
The judge is consistent with sanctions so that participants have a sense of what
to expect. The specific response may depend on factors like the persons stage
of treatment and the particular behavior or relapse involved. Typically, noncompliance may lead to a higher level of care and/or increased drug testing. The
35
36
court may also respond with increased court reporting, daily check-in with the
coordinator, a weekend in jail, or a combination of these sanctions.
A positive test for illicit substances or a negative test for prescribed MAT
medication is considered non-compliance. In such cases, the court notifies the
doctor. Sometimes, doctors give the patient a warning that if this continues, the
doctor will stop prescribing the medication.
What are the sanctions for illicit sale of MAT

medications?
The court coordinator could not think of an instance in which the court learned
a participant was selling medication. If that happened, the court would respond
with a sanction. The court also would expect the treating doctor to stop
prescribing the medication based on concern about its distribution.
Is illicit diversion of MAT medications common?

No. The team has not seen diversion of MAT medications. The assigned
prosecutor explains,
If theyre on [MAT], most of them want to take it. They dont
get it for the purpose of giving it away. I havent seen diversion
happening in this court. [The court] might miss it occasionally
but not for long. If youre doing the monitoring you should be
doing, it can only go on for so long before a flag is thrown that
something is off.
The resource coordinator thinks the court may see less diversion because
the people who choose to go on [MAT] may be older and more mature. They
may have already had multiple treatment attempts and feel more motivated for
recovery.
The judge thinks there is minimal diversion largely due to the courts close
monitoring. Im okay with [MAT] as long as we can monitor it, he concludes.
Lying is part of active addiction, he notes. You need an educated treatment
team and educated judge [or] they will try to get one over on you.
III. Court Profiles
Does allowing MAT create a burden and cost for the

court?
Allowing MAT requires some additional time expenditure but not other concrete
costs. The court may count the buprenorphine strips for MAT recipients in
addition to its other monitoring and spends more time trying to reach doctors
who can be slow to respond. Including MAT also requires educating the team
members and the treatment community about how it works and its impact on
achieving and maintaining recovery. Nonetheless, the team feels strongly that
MAT is a valuable tool for some of
its participants.
The court maintains a list of approved providers, based on criteria
Who pays for MAT?
such as accurate progress reports,
Most participants either have
regular communication, attentive
private insurance or Medicaid
monitoring, and the quality of the
that pays for MAT. Others pay
therapeutic relationship with para significant amount for MAT,
ticipants.
either in co-pays with private
insurance, or through self-pay
if they do not have insurance
coverage. However, even these participants have been able to cover the cost of
MAT, sometimes with the help of family members.
37
38
Downstate Urban Treatment Court

Jurisdiction: A densely populated county within a large city.
Overview
This large court serves a county with well over a million residents and has a
docket of approximately 250 cases. The staff includes a judge, project director,
resource coordinator and four case managers. Other members of the treatment
court team include the assigned prosecutor and defense attorney. Eligible
offenses include non-violent felony offenses to which participants have already
entered pleas with their sentences deferred until program completion.
Approximately one-third of the courts participants have a history, often
lengthy, of opiate addiction; heroin is almost always their drug of choice.
Between 2012 and 2015, about 57 percent of participants were Latino/a , 29
percent were black/African American, 4 percent were white/non-Latino/a, 1
percent was Black/West Indian, and 9 percent were other or unknown race or
ethnicity. Eighty-five percent were male, and 15 percent were female.
Which Opioid Treatment Does the Court Use?

The court permits participants to receive any of the available addiction
medications, in addition to counseling and other services from a state-licensed
treatment program. The court does not allow any participants to receive
addiction medication without these additional services.
The court maintains a list of approved providers, based on criteria such as
accurate progress reports, regular communication, attentive monitoring, and
the quality of the therapeutic relationship with participants. The court avoids
programs with a punitive mindset. The court seeks providers who offer the
full range of treatment options, including medication. If a participant enters the
program already working with one of the providers on the list, they can usually
continue that relationship. If a participants existing provider is not on the
court-approved list, the court will refer him or her to an approved program.
A significant number of individuals entering drug court report prior illicit use
of buprenorphine or methadone, but this does not necessarily bar them from
receiving MAT. The court finds that effective treatment and monitoring increase
III. Court Profiles
the likelihood that participants will use medication as prescribed.

About 85 to 90 percent of the MAT participants receive methadone. About 10
to 15 percent receive buprenorphine. A very small number receive Naltrexone
because few programs provide it, but it is becoming increasingly available. The
court refers people to programs that determine which medication would be
most appropriate. It does not prefer one medication over another.
Some of the barriers to methadone encountered in other parts of the state are
not present in this area; local methadone clinics do not have waitlists and are
relatively close to participants residences.
Treatment decision-making
Clinical staff at the drug court conducts the initial assessment with the standard
psychosocial instrument used by all New York drug courts. Based on assessment
results, staff refers the participant to an appropriate program. The program
then develops the details of the persons treatment plan, including decisions
about medication.
Not all members of this drug court team are confident that MAT is an
appropriate treatment for opioid addiction, nor are they all familiar with the
science supporting MAT. The assigned prosecutor thinks it would be better for
participants not to take medication so they can break free from the chain of
addiction. She explains, however, that her role is to assess if defendants are
eligible for drug treatment court based on their criminal history, not make
determinations about their treatment needs. She thinks that black and white
rules do not help anyone.
The judge also asserts that he is not necessarily an advocate for MAT, but that
he defers to clinicians. When he was first assigned to the drug court, he spoke
with doctors who had worked at treatment programs about their use of MAT.
He concluded that medication could be an important tool and clinicians should
have the full range of available treatments. Accordingly, the court lets clinicians
determine whether to use MAT on a case-by-case basis. The judge does not
weigh in on those determinations, but rather makes decisions about legal
eligibility and sanctions.
39
40
Some participants have concerns about receiving MAT and may be reluctant
to start it, or express an interest in tapering off. In some cases, this may be due
to internalized stigma, i.e., from pressure by staff at treatment programs or
12-step programs to taper off it.
The case management supervisor
The court requires all MAT
says they generally counsel:
participants to receive counseling
Slow down, its OK to be on
and the full array of wraparound
MAT. Think it through. Court
services provided by the treatment
staff try to communicate that
programs.
MAT should not be stigmatized
and can be part of meaningful
recovery. They always encourage
participants to speak with their treatment providers regarding decisions about
MAT to ensure that any decision is well informed. When participants want to
stop taking MAT because they find it burdensome (e.g., because of the daily
clinic visits for methadone, or because of the effects of the medication), the
court still may suggest waiting until after graduation when they will not face
legal consequences if they have difficulty tapering, as people often do.

medication?
The court requires all MAT participants to receive counseling and the full
array of wraparound services provided by the treatment programs. The courts
expectations for MAT participants are the same as for participants who do not
receive medication.
How long do participants stay on MAT?

The length of treatment is based on an individual clinical determination. The
court does not expect participants to stop MAT in order to graduate from the
program. Early on, the court required people to taper off MAT and stay off for
60 days. They saw a pattern of participants coming very close to graduation, but
then having multiple relapses. The court then would order six more months of
treatment, and the cycle often repeated. One-year mandates turned into two-,
III. Court Profiles
three-, or four-year mandates, or sometimes failure and a long prison sentence.

Once the court allowed people to continue with MAT through graduation,
participants were much more successful.

MAT medication?
The court expects the treatment programs to take the lead on monitoring
participants compliance. Like the other profiled courts, this courts strategies to
monitor and encourage compliance are similar to those used for all drug court
participants. Key components of monitoring include the following and generally
apply to all participants, whether or not they receive MAT:
1.
Urine testing
Who tests and how? The court expects treatment programs to conduct
observed urine testing at least two times per week. The court generally only
tests participants (1) upon admission, (2) when they move between phases, (3) if
tests are missing from the program, and (4) upon completion.
2.
Pill and strip counting
Who counts and how? Most participants receive methadone taken under
supervision so there is no need to count strips or pills. For participants receiving
buprenorphine, the court expects the treatment programs to determine if or
when counting is necessary. Naltrexone is injected by a physician; therefore,
there is no pill or strip counting.
3.
Observation
The court expects programs to observe their participants for more subjective
measures, such as how they are functioning generally. There may be indications,
other than drug tests, that a participant needs more intervention.
4. Communication with treatment providers
Court staff emphasizes the importance of good communication with programs.
Regular contact ensures that the court and program can address issues early on.
41
42
Regular contact also helps with monitoring medication use (and misuse) and
progress in treatment generally. Highlights of the courts communication with
treatment providers include:
5.
Use of multiple forms of communication
Programs and the drug court team communicate through email and phone calls,
in addition to formal written reports.
6.
Communication early and often with a problem-solving approach.
The court wants to hear about problems when they arise so they can address
them promptly.
7.
Communication of subjective observations
Subjective observations include unexplained changes in behavior, and not just
objective data like test results and attendance. The court thinks substance
misuse usually becomes apparent through observation and the participants
general functioning.
If there is a lapse in communication with a program (e.g., not returning calls
in a timely manner or not providing information upfront), the court contacts
a manager. In the rare event that communication is still difficult, the court
evaluates whether to continue referring participants to that program.

relapse?
The courts range of responses to non-compliance is generally the same for
all clientsMAT recipients and others. Interventions may include steps like a
contract between the program and the client, or a reassessment of treatment
needs, potentially leading to a higher level of care. The court might require the
participant to write a letter to the judge, extend the length of the court mandate,
or in extreme cases, impose a jail sanction.
In assessing the appropriate intervention if someone relapses while using
MAT, the court considers if the person may not have yet reached the correct
level of medication to achieve a blocking dose. The relapse might indicate a
III. Court Profiles
need to increase medication, rather than to discontinue it. The court seeks input
from the medical practitioner. As a staff member says, it would be unethical
to withhold medication as a sanction. Clinical indications form the basis for
medication decisions.
What are the sanctions for illicit use or sale of MAT

medications?
Participants arrested for selling medication generally receive a jail sanction,
just as they do for the illegal sale of any substance. This is rare, however, and the
project director cannot even remember specific examples.
How pervasive is illicit diversion of MAT medication?

Staff thinks diversion is relatively uncommon among participants. They reduce
its occurrence through monitoring and communicating that diversion results
in clear consequences. As one team member says, [Participants] really dont
want to come into court having messed up. Our judge can be tough. They also
believe that effective treatment decreases the risk of diversion. Since most
participants go to methadone clinics, where staff observes participants taking
their daily dose, the risk of diversion is minimal. Even the assigned prosecutor
who prefers abstinence-based treatments thinks that there is effective
monitoring of MAT and does not have concerns about court outcomes for
participants who receive MAT.
Does allowing MAT create a burden and cost for the

court?
Incorporating MAT has been relatively seamless for this court. In fact, it seems
almost like a non-issue. The judge and assigned prosecutor pointed out that
they rarely even note whether a particular participant is receiving MAT. They
look at how the participant is doing in treatment and other aspects of their lives.
Whether the participant receives MAT does not typically affect that assessment.
In terms of logistics, MAT is available from many of the programs with which
the court already had relationships prior to its incorporation of MAT. The fact
that the programs take responsibility for closely monitoring participants and
43
44
other associated tasks relieves the burden on the court. Moreover, clinical staff
members generally feel that MAT significantly improves treatment outcomes,
thereby reducing the overall burden on the court.
Who pays for MAT?

Almost all participants receive Medicaid coverage for MAT. Some participants
work, but the court has not heard of difficulties paying for MAT once employed.
Almost all participants receive methadone, which is generally the least
expensive form of MAT treatment.
How did this courts MAT program begin?

Prior to 2005, the court saw few opioid addicted individuals and required most
of them to taper off MAT before graduation. Key players, particularly the deputy
district attorney who oversaw drug court, opposed MAT.
In 2005, the court began a misdemeanor program that permitted
MAT and found it to be effective. Additionally, the felony court permitted
some participants to receive MAT in response to letters from doctors with
compelling accounts of participants medical or psychiatric need for MAT.
Those participants tended to be successful. As the drug court evolved, some
staff who initially opposed MAT became more open to its use; others may not
have changed their views, but deferred to clinicians. In 2009, when Rockefeller
Drug Law reforms resulted in the creation of new Judicial Diversion courts and
gave more discretion to judges, the court began permitting all opioid addicted
individuals to receive MAT when clinically indicated.
III. Court Profiles
IV. Specific Issues

for Rural Drug
Courts
45
46
Specific Issues for Rural Drug Courts

Drug courts serving rural areas can face unique challenges when implementing
medication-assisted treatment programs. Yet, many rural courts have found
ways to address hurdles and operate successful programs. Three of the 10 courts
interviewed for this report serve exclusively rural areas; another five are in
cities or suburbs with jurisdiction over rural areas. What follows are some of the
challenges and solutions learned from these courts.
Scarcity of nearby treatment and limited transportation

All of the courts noted that in rural areas, treatment is limited, distances to
programs greater, and public transportation minimal. Methadone maintenance
treatment is generally the scarcest of MAT modalities, with opioid treatment
programs far away and/or at capacity. The nearest methadone program to one
rural court, for example, is an hours drive, with long waiting lists.
Because of the limited availability of methadone, most of these courts rely
on buprenorphinegenerally from the same outpatient treatment programs
attended by other participants. In two courts, a small number of participants
receive buprenorphine from private doctors, even though the courts prefer to
use licensed treatment programs. Because of concerns about the practices of
some private doctors, one program requires participants to receive their MAT
from a licensed treatment program until they complete the program, at which
time they may receive it from a private doctor. Another court does not permit
the use of private doctors who accept cash only.
These rural courts expect to incorporate injectable naltrexone as it
becomes increasingly available. Travel distances make injectable naltrexone
and buprenorphine more practical than methadone because they require
fewer appointments. Courts also note that where participants rely on
medi-cab reimbursements for travel, an essential strategy is to have them
receive medication at their treatment program so they do not have to attend
appointments at different locations.
Because treatment providers and court staff can have closer relationships
in small towns, some rural courts have tried to expand treatment capacity by
urging programs to offer MAT medication.
IV. Specific Issues for Rural Courts
Smaller court staff

Rural courts typically have small staffsjust one person in addition to the
judgewhich can make monitoring more burdensome. To help stretch
resources, some of these courts rely on the treatment programs and probation
officers (where applicable) to conduct the lions share of the monitoring.
For example, one rural court conducts random urine screens and monitors
participants through behavioral observation, but only the treatment programs
and probation conduct strip counting for buprenorphine. One court coordinator
also notes that because they operate in a small community, they have especially
close communication with the treatment providers. Were a tight team,she
says, and feels very lucky to be in a small town where the court can develop
close relationships with the treatment programs.
In sum, rural courts may face different challenges to incorporating MAT. But
as in other areas, there are viable strategies to make MAT available to treatment
court participants.
47
48
Conclusion
48
Conclusion
Conclusion
Scientific evidence overwhelmingly shows that MAT is a critical tool in the
treatment of opioid addiction and essential in fighting the opioid epidemic. Drug
treatment courts can play a key role in ensuring that participants have access to
this effective, evidence-based treatment, while also reducing crime. In fact, the
law in New York now requires it.31
As shown in this report, incorporating MAT into a courts operations is not
onerous but works best when done with planning and coordination. While use
of MAT can pose challenges, especially when key players are not all on board,
an array of strategies are available to address these challenges. Whether a court
is rural, suburban or urban, or in any region of the state, it can use this reports
concrete suggestions to begin or improve a MAT program. While MAT is not
appropriate for every participant with opioid addiction, decisions about its
use require individualized evaluations based on objective medical evidence.
As such, MAT should be a key component in every courts tool-kit for treating
opioid addiction.
49
50
Endnotes
50
Endnotes
1. Memorandum in support of bill S4239B, available at http://www.nysenate.gov/legislation/

bills/2015/S4239B.
2. NY Crim. Proc. Law 216.05(5) and (9)(a).
3. Id. 1.
4. LEGAL ACTION CENTER, LEGALITY OF DENYING ACCESS TO MEDICATION ASSISTED TREATMENT IN THE CRIMINAL JUSTICE SYSTEM (Dec. 1, 2011),), http://lac.
org/wp-content/uploads/2014/12/MAT_Report_FINAL_12-1-2011.pdf.
5. Harlon Matusow, et al., Medication assisted treatment in US drug courts: Results from a nationwide survey of availability, barriers and attitudes, J. SUBSTANCE ABUSE TREATMENT
(2012), 4, available at http://dx.doi.org/10.1016/j.jsat2012.10.004.
6. Though the term MAT can also encompass treatment for a range of substance addictions,
this report focuses only on the use of medication to treat opioid addiction.
7. Methadone is also prescribed for pain. This report, however, refers only to methadone maintenance treatment for opioid addiction.
8. MADY CHALK ET AL., TREATMENT RESEARCH INSTITUTE, FDA APPROVED MEDICATIONS FOR THE TREATMENT OF OPIATE DEPENDENCE: LITERATURE REVIEWS
ON EFFECTIVENESS AND COST-EFFECTIVENESS (Jun. 2013) at 8, 11, 24-25, available
at http://www.asam.org/docs/default-source/advocacy/aaam_implications-for-opioid-addiction-treatment_final; NATIONAL INSTITUTES OF HEALTH, NIH CONSENSUS STATEMENT: EFFECTIVE MEDICAL TREATMENT OF OPIATE ADDICTION (1997), at 15-17,
available at http://consensus.nih.gov/1997/1998TreatOpiateAddiction108PDF.pdf; OFFICE
OF NATIONAL DRUG CONTROL POLICY, TREATMENT PROTOCOL EFFECTIVENESS
STUDY (Mar. 1996), at 4, available at https://www.ncjrs.gov/ondcppubs/publications/treat/
trmtprot.html; NATIONAL INSTITUTE OF DRUG ABUSE (NIDA), TOPICS IN BRIEF,
MEDICATION-ASSISTED TREATMENT FOR OPIOID ADDICTION (Apr. 2012), available at http://www.drugabuse.gov/sites/default/files/tib_mat_opioid.pdf; National Institutes of
Health, NIH Consensus Statement: Effective Medical Treatment of Opiate Addiction (1997),
at 15-17, available at http://consensus.nih.gov/1997/1998TreatOpiateAddiction108PDF.pdf;
Jeannia F. Ju et al., Forced withdrawal from methadone maintenance therapy in criminal justice
settings: A critical treatment barrier in the United States, J. SUBSTANCE ABUSE TREATMENT
(2013), (citing Hedrich et al.; Kinlock et al., 2009; Larney et al., 1998; Sees et al., 2000; Sullivan
et al., 2005; Zaller et al., 2010); John Kakko, MD et al., 1-year retention and social function
after buprenorphine-assisted relapse prevention treatment for heroin dependence in Sweden: a
randomized, placebo-controlled trial, 361 No.9358 LANCET, 662-668 (Feb. 22, 2013), available
at http://www.ncbi.nlm.nih.gov/pubmed/12606177.
9. NIDA INTERNATIONAL PROGRAM, METHADONE RESEARCH WEB GUIDE, PART B:
20 QUESTIONS AND ANSWERS REGARDING METHADONE MAINTENANCE TREATMENT RESEARCH, PART B, B-1 (2013), https://www.drugabuse.gov/sites/default/files/pdf/
partb.pdf.
10. Nora D. Volkow et al., Medication-Assisted Therapies Tackling the Opioid-Overdose Epidemic, N. ENGL. J. OF MED., May 29, 2014,2014, at 2064, available at http://www.nejm.org/doi/
full/10.1056/NEJMp1402780, (citing Robert P. Schwartz et al., Opioid Agonist treatments and
heroin overdose deaths in Baltimore, Maryland, 1995-2009, 103 No. 5 AM. J. PUB. HEALTH
(2013) available at http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2012.301049).
11. John Kakko, MD et al., 1-year retention and social function after buprenorphine-assisted relapse prevention treatment for heroin dependence in Sweden: a randomized, placebo-controlled
51
52
trial, 361 No.9358 LANCET, 662-668 (Feb. 22, 2013), available at http//www.ncbi.nlm.nih.gov/
pubmed/12606177.
12. Ingrid A. Binswanger, MD et al., After Prison Release: Opioid Overdose and Other Causes of
Death, Risk Factors, and Time Trends From 1999 to 2009, 159 No. 9 ANN. INTERN. MED.
(Nov. 5, 2013) available at http://annals.org/article.aspx?articleid=1763230.
13. NATIONAL INSTITUTE OF DRUG ABUSE (NIDA), TOPICS IN BRIEF, MEDICATION-ASSISTED TREATMENT FOR OPIOID ADDICTION (Apr. 2012), available at http://
www.drugabuse.gov/sites/default/files/tib_mat_opioid.pdf.
14. Timothy W. Kinlock et al., A Study of Methadone Maintenance for Male Prisoners: 3-Month
Post Release Outcomes, CRIM. JUST. BEHAV. (Jul. 8 2008), available at http://www.ncbi.nlm.
nih.gov/pmc/articles/PMC2443939/.
15. Id.
16. Joshua D. Lee et al., Opioid treatment at release from jail using extended-release naltrexone,
ADDICTION (2015), available at http://onlinelibrary.wiley.com/doi/10.1111/add.12894/epdf.
18. See, e.g., U.S. DEPT OF HEALTH & HUMAN SVCS., NATL INST. OF HEALTH, NATL
INST. ON DRUG ABUSE, PRINCIPLES OF DRUG ADDICTION TREATMENT, NIH PUB.
No. 12-4180, 26-27 (3rd Ed., Dec. 2012), available at http://www.drugabuse.gov/sites/default/
files/podat_1.pdf.
19. National Institute on Drug Abuse, supra note 8, at 2.
20. American Society of Addiction Medicine, The ASAM National Practice Guideline for the Use
of Medications in the Treatment of Addiction Involving Opioid Use, (May 2015), available at
http://www.asam.org/docs/default-source/practice-support/guidelines-and-consensus-docs/
national-practice-guideline.pdf.
21. CENTER FOR DISEASE CONTROL, METHADONE MAINTENANCE TREATMENT,
IDU/HIV PREVENTION (Feb. 2002), available at http://www.nhts.net/media/Methadone%20
Maintenance%20Treatment%20(20).pdf .
22. SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION (SAMHSA), FEDERAL GUIDELINES FOR OPIOID TREATMENT PROGRAMS, (Mar. 2015), 25
available at http://store.samhsa.gov/shin/content/PEP-15FEDGUIDEOTP/PEP15-FEDGUIDEOTP.pdf.
23. OFFICE OF NATIONAL DRUG CONTROL POLICY, MEDICATION-ASSISTED TREATMENT FOR OPIOID ADDICTION (Sept. 2012), 3, available at http://www.whitehouse.gov/
sites/default/files/ondcp/recovery/medication_assisted_treatment_9-21-20121.pdf.
24. U.S. DEPT. OF HEALTH & HUMAN SVCS., SUBSTANCE ABUSE & MENTAL HEALTH
ADMIN., MEDICATION-ASSISTED TREATMENT FOR OPIOID ADDICTION IN OPIOID TREATMENT PROGRAMS, TREATMENT IMPROVEMENT PROTOCOL (TIP)
43 (2005), available at http://store.samhsa.gov/product/TIP-43-Medication-Assisted-Treatment-for-Opioid-Addiction-in-Opioid-Treatment-Programs/SMA12-4214. See also David
Mee-Lee, ed., The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and
Co-Occurring Conditions, (Oct. 14, 2013), e-page 293, (noting that the notion that the duration
of treatment varies is a foundational principle of the ASAM criteria.)
Endnotes
26. U.S. DEPT OF HEALTH & HUMAN SVCS, CENTERS FOR DISEASE CONTROL, METHADONE MAINTENANCE TREATMENT (Feb. 2002), available at http://www.nhts.net/
media/Methadone%20Maintenance%20Treatment%20(20).pdf, (citing NIDA, PRINCIPLES
OF DRUG ADDICTION TREATMENT: A RESEARCH BASED GUIDE (1999), available at
http://www.drugabuse.gov/sites/default/files/podat_1.pdf).
27. Nora D. Volkow, Statement to the Senate Caucus on International Narcotics Control, Americas
Addiction to Opioids: Heroin and Prescription Drug Abuse, May 14, 2014, available at https://
www.hsdl.org/?view&did=754557.
28. OFFICE OF NATIONAL DRUG CONTROL POLICY, MEDICATION-ASSISTED TREATMENT FOR OPIOID ADDICTION (Sept. 2012), available at http://www.whitehouse.gov/
sites/default/files/ondcp/recovery/medication_assisted_treatment_9-21-20121.pdf (citing Ed
Day & John Strang, (2010)); Outpatient versus inpatient opioid detoxification: a randomized
controlled trial [Electronic Version], 40J40J. OF SUBSTANCE ABUSE TREATMENT (Nov. 1,
2010), 46-66).
29. OFFICE OF NATIONAL DRUG CONTROL POLICY, MEDICATION-ASSISTED TREATMENT FOR OPIOID ADDICTION (Sept. 2012), available at http://www.whitehouse.gov/
sites/default/files/ondcp/recovery/medication_assisted_treatment_9-21-20121.pdf.
30. Information about the LOCADTR 3 tool is available through the New York State Office of
Alcoholism and Substance Abuse Services, at https://oasas.ny.gov/treatment/health/locadtr/
index.cfm.
31. NY Crim. Proc. Law 216.05(5) and (9)(a).
53
54
Appendices
54
55
Appendices
Appendix A
FDA-Approved Medications for Substance Use Disorders
Name
Molecular
Structure
Treatment Use
Controlled Substance?
Abuse Potential
Trade Name
Naltrexone
(Vivitrol)
Antagonist
Buprenorphine
Methadone
Agonist
Agonist
Opioid
dependence
Schedule 0
No
Vivitrol
Opioid dependence
Opioid dependence
Schedule II
Yes
Methadone
How administered
Intramuscular
injection
How the medication works
By blocking
opioid
receptors, it
blocks cuetriggered
craving
Special licensing or
credential required?
Year approved by FDA for
Addiction Treatment
No
Schedule III
Yes
Suboxone*
*includes naloxone
Oral tablet or
sublingual film taken
once daily
A long-acting partial
opioid, it relieves
withdrawal,
decreases craving,
and prevents
euphoria if other
opioids are used
Varies by state
2006
2002
Physician training required?
No
Typical Duration
Detoxification or
Stabilization
Up to 30 days
Detoxification
& 7-10 days
of complete
abstinence
from opioids
Yes 8 hours of
training required
1 day
Detoxification
Oral Solution
A long-acting full
opioid that relieves
withdrawal, blocks
craving, and prevents
euphoria if other
opioids are used
Yes
1947 Approved
dispersible tablet for
treatment of
addiction
No
1 day
Can be used for
detoxification and/or
stabilization
OFFICE OF NATIONAL DRUG CONTROL POLICY, MEDICATION-ASSISTED TREATMENT FOR OPIOID ADDICTION (Sept. 2012), 5, available
at https://www.whitehouse.gov/sites/default/files/ondcp/recovery/medication_assisted_treatment_9-2120121.pdf.
56
Appendix B
RESOLUTIONOFTHEBOARDOFDIRECTORS
ONTHEAVAILABILITYOFMEDICALLYASSISTEDTREATMENT(M.A.T.)
FORADDICTIONINDRUGCOURTS
WHEREAS, addiction to illicit drugs and alcohol is, in part, a neurological or neurochemical
disordercharacterizedbychronicphysiologicalchangestobrainregionsgoverningmotivation,
learning,attention,judgment,insight,andaffectregulation15;and
WHEREAS, certain medically assisted treatments (M.A.T.) for addiction including antagonist
medications such as naltrexone, agonist medications such as methadone, and partial agonist
medicationssuchasbuprenorphinehavebeenproventhroughrigorousscientificstudiesto
improveaddictedoffendersretentionincounselingandreduceillicitsubstanceuse,rearrests,
technicalviolations,reincarcerations,hepatitisCinfections,andmortality612;and
WHEREAS,theavailabilityanduseofM.A.T.foraddictionisendorsedbyleadingscientificand
practitionerorganizationsinthesubstanceabusetreatmentfield1317;and
WHEREAS, despite the proven efficacy of M.A.T., it is infrequently available for addicted
individualsinvolvedinthecriminaljusticesystem1820;and
WHEREAS, the conditions for participation in Drug Court, like those of probation, should be
basedonaparticularizeddeterminationineachcasethattheconditionsarereasonablyrelated
tothegoalsofprotectingpublicsafety,rehabilitatingtheoffender,orensuringtheoffenders
appearanceincourt21:
Appendices
NOW,THEREFORE,BEITRESOLVEDTHAT:
1. Drug Court professionals have an affirmative obligation to learn about current
researchfindingsrelatedtothesafetyandefficacyofM.A.T.foraddiction.
2. Drug Court programs should make reasonable efforts to attain reliable expert
consultationontheappropriateuseofM.A.T.fortheirparticipants.Thisincludes
partnering with substance abuse treatment programs thatoffer regular access to
medicalorpsychiatricservices.
3. DrugCourtsdonotimposeblanketprohibitionsagainsttheuseofM.A.T.fortheir
participants.ThedecisionwhetherornottoallowtheuseofM.A.T.isbasedona
particularized assessment in each case of the needs of the participant and the
interestsofthepublicandtheadministrationofjustice.
4. DrugCourtjudgesbasetheirdecisionwhetherornottopermittheuseofM.A.T.,
in part, on competent expert evidence or consultation. In cases in which a
participant,theparticipantslegalcounsel,oramedicalexperthasrequestedthe
possible use of M.A.T., the judge articulates the rationale for allowing or
disallowingtheuseofaddictionmedication.
5. NothinginthisResolutionpreventsaDrugCourtfromimposingconsequencesona
participant for failing to respond to drugfree counseling, if M.A.T. was made
availabletotheparticipantbutwasrefused.
__________________________________________________________
Baler, R. D., & Volkow, N. D. (2006). Drug addiction: The neurobiology of disrupted selfcontrol. Trends in
MolecularMedicine,12,559566.
Chandler,R.K.,Fletcher,B.W.,&Volkow,N.D.(2009).Treatingdrugabuseandaddictioninthecriminaljustice
system:Improvingpublichealthandsafety.JournaloftheAmericanMedicalAssociation,301,183190.
Dackis, C., & OBrien, C. (2005). Neurobiology of addiction: Treatment and public policy ramifications. Nature
Neuroscience,8,14311436.
Goldstein,R.Z.,Craig,A.D.,Bechara,A.,Garavan,H.,Childress,A.R.,Paulus,M.P.,&Volkow,N.D.(2009).The
neurocircuitryofimpairedinsightindrugaddiction.Cell,13,372380.
McLellan,A.T.,Lewis,D.C.,OBrien,C.P.,&Kleber,H.D.(2000).Drugdependence,achronicmedicalillness:
Implicationsfortreatment,insurance,andoutcomesevaluation.JAMA,284,16891695.
Cornish, J. W., Metzger, D., Woody, G. E., Wilson, D., McLellan, A. T., Vandergrift, B. (1997). Naltrexone
pharmacotherapy for opioid dependent federal probationers. Journal of Substance Abuse Treatment, 14,
529534.
57
58
Dolan,K.A.,Shearer,J.,White,B.,Zhou,J.,Kaldor,J.,&Wodak,A.D.(2005).Fouryearfollowupofimprisoned
maleheroinusersandmethadonetreatment:Mortality,reincarcerationandhepatitisCinfection.Addiction,
100,820828.
Gordon,M.S.,Kinlock,T.W.,Schwartz,R.P.,&OGrady,K.E.(2008).Arandomizedclinicaltrialofmethadone
maintenanceforprisoners:Findingsat6monthspostrelease.Addiction,103,13331342.
Kinlock, T.W., Gordon, M.S., Schwartz,R. P., &OGrady,K. E.(2008). A study of methadone maintenancefor
maleprisoners:Threemonthpostreleaseoutcomes.CriminalJustice&Behavior,35,3447.
10
Magura, S., Lee, J. D., Hershberger, J., Joseph, H., Marsch, L., Shropshire, C., & Rosenblum, A. (2009).
Buprenorphine and methadone maintenance in jail and postrelease: A randomized clinical trial. Drug &
AlcoholDependence,99,222230.
11
OBrien,C.P.,&Cornish,J.W.(2006).Naltrexoneforprobationersandprisoners.JournalofSubstanceAbuse
Treatment,31,107111.
12
Stallwitz, A., & Stover, H. (2006). The impact of substitution treatment in prisonsA literature review.
InternationalJournalofDrugPolicy,18,464474.
13
NationalInstituteonDrugAbuse.(2006).Principlesofdrugabusetreatmentforcriminaljusticepopulations[NIH
Pub.No.065316].Bethesda,MD:Author.
14
CenterforSubstanceAbuseTreatment.(2004).Clinicianguidelinesfortheuseofbuprenorphineinthetreatment
ofopioidaddiction[TreatmentImprovementProtocol(TIP)Series40,DHHSPublicationNo.(SMA)043939].
Rockville,MD:SubstanceAbuseandMentalHealthServicesAdministration.
15
Center for Substance Abuse Treatment. (2005). Medicationassisted treatment for opioid addiction in opioid
treatment programs [Treatment Improvement Protocol (TIP) Series 43, DHHS Publication No. (SMA) 05
4048].Rockville,MD:SubstanceAbuseandMentalHealthServicesAdministration.
16
CenterforSubstanceAbuseTreatment(2009).Incorporatingalcoholpharmacotherapiesintomedicalpractice.
[Treatment Improvement Protocol (TIP) Series 49. HHS Publication No. (SMA) 094380]. Rockville, MD:
SubstanceAbuseandMentalHealthServicesAdministration.
17
NationalDrugCourtInstitute.(2002).Methadonemaintenanceandotherpharmacotherapeuticinterventionsin
thetreatmentofopioiddependence[PractitionerFactSheetVol.III,No.I].Alexandria,VA:Author.
18
Taxman,F.S.,Perdoni,M.L.,&Harrison,L.D.(2007).Drugtreatmentservicesforadultoffenders:Thestateof
thestate.JournalofSubstanceAbuseTreatment,32,239254.
19
Nunn,A.,Zaller,N.,Dickman,S.,Trimbur,C.,Nijhawan,A.,&Rich,J.D.(2009).Methadoneandbuprenorphine
prescribing and referral practices in US prison systems: Results from a nationwide survey. Drug & Alcohol
Dependence,105,8388.
20
Chandler,etal.(2009),supranote2.
21
See,e.g.,Robertsv.UnitedStates,320U.S.264,272,88L.Ed.41,64S.Ct.113(1943)(holdingbasicpurposeof
probationistoprovideindividualizedprogramofrehabilitation);Commonwealthv.Wilson,2010PASuper
233,11A.3d519(2010)(findingprimaryconcernofprobationisrehabilitation,andprobationordermustbe
unique and individualized); In re. Victor L., 182 Cal.App.4th 902, 106 Cal.Rptr.3d 584 (2010) (requiring
individualized approach to probation conditions); State v. Philipps, 242 Neb. 894, 496 N.W.2d 874 (1993)
(findingitnecessarytogivecareful,humaneandcomprehensiveconsiderationtoparticularsituationofeach
probationer); Commonwealth v. Hartman, 908 A.2d 316, 320 (Pa. Super. 2006) (stating conditions of
probation must be reasonable); People v. Beaty, 181 Cal.App.4th 644, 105 Cal.Rptr.3d 76 (2010) (holding
restrictions on medical marijuana by probationers must be reasonably related to offense and based on
medical evidence); People v. Carbajal,10Cal.4th1114,43 Cal.Rptr.2d 681,899 P.2d 67(1995)(concluding
probationconditionsmustbereasonablyrelatedtothecrimeorriskoffuturecriminality).
59
Appendices
Appendix C
Medication-Assisted Treatment for Opioid Addiction

Myths and Facts
Medication-assisted treatment (MAT) for opioid addiction is the use of medications, in
combination with counseling and behavioral therapies, to provide a whole-patient approach
to treatment. MAT utilizes medications, such as methadone, buprenorphine, and injectable
naltrexone, to stabilize brain chemistry, block the euphoric effects of opioids, relieve
physiological cravings, and normalize body functions. Numerous studies have shown that
MAT reduces illicit drug use, disease rates, and criminal activity among opioid addicted
persons.1 Despite overwhelming evidence of MATs benefits, many people view it
negatively. As a result, they do not use MAT and sometimes prohibit it even when
clinically appropriate. Following are common myths and facts about MAT. Relying on the
facts will increase the chance that people will enter and sustain recovery.
Myth: MAT substitutes one addiction for another.
Fact: Though two of the three MAT medications are opioid-based, they are fundamentally
different from short-acting opioids such as heroin and prescription painkillers. The latter go
right to the brain and narcotize the individual, causing sedation and the euphoria known as
a high. In contrast, addiction medications like methadone and buprenorphine, when
properly prescribed, reduce drug cravings and prevent relapse without causing a high.2
They help patients disengage from drug seeking and related criminal behavior and become
more receptive to behavioral treatments.3 Injectable naltrexone is not opioid based and does
not result in physical depenence.4
Myth: Addiction medications are a crutch that prevents true recovery.
Fact: Leading addiction professionals and researchers have concluded that individuals
stabilized on MAT can achieve true recovery. This is because such individuals do not use
illicit drugs; do not experience euphoria, sedation, or other functional impairments; and do
not meet diagnostic criteria for addiction, such as loss of volitional control over drug use.5
MAT consists not only of medication but also of behavioral interventions like counseling.
The medication normalizes brain chemistry so individuals can focus on counseling and
participate in behavioral interventions necessary to enter and sustain recovery.6
Myth: MAT should not be long term.
Fact: There is no one-size-fits-all duration for MAT. The Substance Abuse and Mental
Health Services Administration (SAMHSA) recommends a phased approach,
beginning with stabilization (withdrawal management, assessment, medication induction,
and psychosocial counseling), and moving to a middle phase that emphasizes medication
maintenance and deeper work in counseling. The third phase is ongoing rehabilitation,
when the patient and provider can choose to taper off medication or pursue longer term
maintenance, depending on the patients needs.7 For some patients, MAT could be
Legal Action Center
February 23, 2016 | www.lac.org
60
indefinite.8 The National Institute on Drug Abuse (NIDA) describes addiction

medications as an essential component of an ongoing treatment plan to enable individuals
to take control of their health and their lives.9 For methadone maintenance, NIDA states
that 12 months of treatment is the minimum.10
Myth: Requiring people to taper off MAT helps them get healthy faster.
Fact: Requiring people to stop taking their addiction medications is counter-productive and
increases the risk of relapse.11 Because tolerance to opioids fades rapidly, one episode of
opioid misuse after detoxification can result in life-threatening or deadly overdose.12
Myth: Courts are in a better position than doctors to decide appropriate drug treatment.
Fact: Deciding the appropriate treatment for a person with opioid addiction is a matter of
physician discretion, taking into consideration the relevant medical standards and the
characteristics of the individual patient.13 Just as judges would not decide that a person
should treat her diabetes through exercise and diet alone, and instruct her to stop taking
insulin, courts are also not trained to make medical decisions with respect to medicallyaccepted addiction treatment.
MADY CHALK ET AL., TREATMENT RESEARCH INSTITUTE, FDA APPROVED MEDICATIONS FOR THE TREATMENT OF
OPIATE DEPENDENCE: LITERATURE REVIEWS ON EFFECTIVENESS AND COST-EFFECTIVENESS (Jun. 2013) at 8, 11, 2425, available at http://www.asam.org/docs/default-source/advocacy/aaam_implications-for-opioid-addictiontreatment_final; NATIONAL INSTITUTES OF HEALTH, NIH CONSENSUS STATEMENT: EFFECTIVE MEDICAL TREATMENT
OF OPIATE ADDICTION (1997), at 15-17, available at http://consensus.nih.gov/1997/1998TreatOpiateAddiction
108PDF.pdf; NATIONAL INSTITUTE OF DRUG ABUSE (NIDA), TOPICS IN BRIEF, MEDICATION-ASSISTED TREATMENT
FOR OPIOID ADDICTION (Apr. 2012), available at http://www.drugabuse.gov/sites/default/files/tib_mat_opioid.pdf.
NIDA, supra note 1, at 1.

See, e.g., NIDA, PRINCIPLES OF DRUG ADDICTION TREATMENT 11 (Martin W. Adler, Ph.D. et al., eds. 3d ed., 2012),
available at http://www.drugabuse.gov/sites/default/files/podat_1.pdf.
4
5
See, e.g., WILLIAM L. WHITE & LISA MOJER-TORRES, RECOVERY -ORIENTED METHADONE MAINTENANCE 5 (2010); THE
AMERICAN SOCIETY OF ADDICTION MEDICINE, THE ASAM CRITERIA: TREATMENT CRITERIA FOR ADDICTIVE, SUBSTANCERELATED, AND CO-OCCURRING CONDITIONS 5 (David Mee-Lee ed., 2013), available at
http://www.williamwhitepapers.com/pr/__books/full_texts/2010Recovery_orientedMethadoneMaintenance.pdf.
6
NIDA, DRUG FACTS: TREATMENT APPROACHES FOR DRUG ADDICTION (2009), available at
http://www.drugabuse.gov/publications/drugfacts/treatment-approaches-drug-addiction.
7
OFFICE OF NATIONAL DRUG CONTROL POLICY, MEDICATION-ASSISTED TREATMENT FOR OPIOID ADDICTION 3 (2012),
available at http://www.whitehouse.gov/sites/default/files/ondcp/recovery/medication_assisted_treatment_9-2120121.pdf.
8
SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION, MEDICATION-ASSISTED TREATMENT FOR OPIOID
ADDICTION IN OPIOID TREATMENT PROGRAMS: A TREATMENT IMPROVEMENT PROTOCOL TIP 43 (2008), available at
http://store.samhsa.gov/shin/content/SMA12-4108/SMA12-4108.pdf.
9
10
NIDA, UNDERSTANDING DRUG ABUSE AND ADDICTION, (2007) available at http://www.drugabuse.gov/publications/
teaching-packets/understanding-drug-abuse-addiction/section-iii/6-duration-treatment.
11
OFFICE OF NATIONAL DRUG CONTROL POLICY, supra note 5, at 3 (citing E. Day & J. Strang, Outpatient Versus Inpatient
Opioid Detoxification: A Randomized Controlled Trial, 40 J. OF SUBSTANCE ABUSE TREATMENT, 1, 56-66 (2010)).
12
OFFICE OF NATIONAL DRUG CONTROL POLICY, supra note 5, at 3.
13
See, e.g., THE AMERICAN SOCIETY OF ADDICTION MEDICINE, THE ASAM CRITERIA: TREATMENT CRITERIA FOR
ADDICTIVE, SUBSTANCE-RELATED, AND CO-OCCURRING CONDITIONS (David Mee-Lee, ed., 2013).
3
Legal Action Center

February 23, 2016 | www.lac.org
61
Appendices
Appendix D
Medication-Assisted Treatment for Opioid Addiction April 2012

Addiction to opioids (e.g., heroin, morphine, prescription pain

relievers) is a serious global problem that affects the health, social,
and economic welfare of all societies. An estimated 1221 million
people worldwide abuse opioids, with 1.9 million people in the U.S.
addicted to prescription opioid pain relievers in 2010 and 359,000
addicted to heroin. Consequences of this abuse have been
devastating and are on the rise. For example, the number of
unintentional overdose deaths from prescription pain relievers has
soared in the U.S., quadrupling since 1999.
Opioids act on specific receptors in the brain and

the body, which also interact with naturally
produced substances known as endorphins or
enkephalins important in regulating pain. While
prescription pain relievers can be highly beneficial if
used as prescribed, opioids as a general class of
drugs have a high potential for abuse.

Abuse of opioids, especially heroin, is also linked
with the transmission of human immunodeficiency
virus (HIV), hepatitis, sexually transmitted
infections (STIs), and other blood-borne diseases
mostly through the use of unsterile drug
paraphernalia, but also through the risky behavior
that drug abuse may engender. Thus, treatment of
drug abuse not only frees individuals from the
vicious cycle of addiction, but can also prevent
related adverse health consequences.

Medications A Critical Component of
Opioid Addiction Treatment

Drug abuse changes the way the brain works,

resulting in compulsive behavior focused on drug
seeking and use, despite sometimes devastating
consequencesthe essence of addiction. Therefore, drug abuse treatment must address these brain changes, both in the
short and long term. When people addicted to opioids first quit, they undergo withdrawal symptoms, which may be severe
(pain, diarrhea, nausea and vomiting). Medications can be helpful in this detoxification stage to ease craving and other
physical symptoms, which often prompt relapse. However, this is just the first step in treatment. Medications may also
become an essential component of an ongoing treatment plan, enabling opioid-addicted persons to regain control of their
health and their lives.

Medications developed to treat opioid addiction work through the same receptors as the addictive drug, but are safer and
less likely to produce the harmful behaviors that characterize addiction. Three types include (1) agonists, which activate
opioid receptors; (2) partial agonists, which also activate opioid receptors but produce a diminished response; and (3)
antagonists, which block the receptor, and interfere with the rewarding effects of opioids. Physicians prescribe a particular
medication based on a patients specific medical needs and other factors. Effective medications include:

Methadone (Dolophine or Methadose), a slow-acting, opioid agonist. Methadone is taken orally, so that it reaches
the brain slowly, dampening the high that occurs with other routes of administration while preventing withdrawal
symptoms. Methadone has been in use since the 1960s to treat heroin addiction and is still an excellent treatment
option, particularly for patients that do not respond well to other medications; however, it is only available through
approved outpatient treatment programs, where it is dispensed to patients on a daily basis.
Buprenorphine (Subutex, Suboxone), a partial opioid agonist. Buprenorphine relieves drug cravings without
producing the high or dangerous side effects of other opioids. Suboxone is a novel formulation, taken orally, that
combines buprenorphine with naloxone (an opioid antagonist) to ward off attempts to get high by injecting the
medication. If an addicted patient were to inject Suboxone, the naloxone would induce withdrawal symptoms,
which are averted when taken orally as prescribed. The FDA approved buprenorphine in 2002, making it the first
medication eligible to be prescribed by certified physicians through the Drug Addiction Treatment Act. This
approval eliminates the need to visit specialized treatment clinics, expanding treatment access.
Naltrexone (Depade, Revia) an opioid antagonist. Naltrexone is not addictive or sedating and does not result in
physical dependence; however, poor patient compliance has limited its effectiveness. Recently an injectable long
acting formulation of naltrexone called Vivitrol received FDA approval for treating opioid addiction. Given as a
monthly injection, Vivitrol should improve compliance by eliminating the need for daily dosing. To avoid withdrawal
symptoms, Vivitrol should be used only after a patient has undergone detoxification. Vivitrol provides an effective
alternative for individuals who are unable to or choose not to engage in agonist-assisted treatment.

Benefits of Medication-Assisted Treatment Beyond Reducing Drug Use

Scientific research has established that medication-assisted
treatment of opioid addiction increases patient retention
and decreases drug use, infectious disease transmission,
and criminal activity. For example, studies among criminal
offenders, many of whom enter the prison system with drug
abuse problems, showed that methadone treatment begun
in prison and continued in the community upon release
extended the time parolees remained in treatment, reduced
further drug use, and produced a three-fold reduction in
criminal activity.

Investment in medication-assisted treatment of opioid
addiction also makes good economic sense. For
methadone, every dollar invested in treatment generates an
estimated $45 return.

Methadone Treatment Pre-and Post-Release Increases

Treatment RetenJon & Reduces Drug Use
Findings at 12 Months Post-Release
Methadone Referral only
Methadone Transfer on Release
Methadone Pre- & Post-Release
65.6
100
Percentage
62
80
60
48.7
17.3
20
66.6
43.2
36.7
40
71.9
25
0
% in Community-Based % Opioid Test PosiJve % Cocaine Test PosiJve
Tx
Kinlock, Gordon, Schwartz, Fitzgerald, OGrady (2009). Journal of Substance Abuse
Treatment. A Randomized Clinical Trial of Methadone Maintenance for Prisoners

Research Reveals New Strategies for Addiction Medications

NIDA is committed to supporting research to improve opioid addiction treatment, including behavioral therapies, which can
be an important component of long-term recovery. Equally important is ensuring that these improvements reach all
affected communities.

Improved medications Probuphine is a long-acting version of buprenorphine that is showing promise in clinical trials. An
implant inserted under the skin, Probuphine can deliver medication continuously for 6 months. Like Vivitrol, it aims to
prevent abuse and diversion and increase treatment adherence by eliminating the need for daily dosing.

Vaccine research Vaccines are being developed to help combat a variety of addictions including heroin. A heroin vaccine,
currently under development, would corral heroin in the bloodstream and prevent it from reaching the brain and exerting its
euphoric effects. This approach could guard against relapse and be an effective addition to a comprehensive treatment plan
for heroin addiction.

Reaching Into the Community

NIDA is collaborating with SAMHSA and others to accelerate the translation of research discoveries into clinical practice,
including the use of medication-assisted treatment. To learn more about these efforts, please visit:
http://www.drugabuse.gov/publications/nidasamhsa-blending-initiative

For further information please visit NIDA on the web at www.drugabuse.gov or contact:
Public Information and Liaison Branch

Office of Science Policy and Communications
Phone 301-443-1124/Fax 301-443-7397
information@nida.nih.gov
Appendices
Appendix E
Further Resources
Adult Drug Courts and Medication-Assisted Treatment for Opioid Dependence,
(Summer 2014), by Substance Abuse and Mental Health Services Administration
(SAMSHA), available at http://store.samhsa.gov/shin/content//SMA14-4852/
SMA14-4852.pdf.
Medication-Assisted Treatment for Opioid Addiction: Facts for Families and
Friends, (Summer 2014), by Substance Abuse and Mental Health Services
Administration (SAMSHA), available at http://store.samhsa.gov/shin/content//
SMA14-4443/SMA14-4443.pdf.
Medication Assisted Therapies Tackling the Opioid Overdose Epidemic, by
Volkow, N., Frieden, T. et al., in New England Journal of Medicine, (May 29,
2014), available at http://www.nejm.org/doi/full/10.1056/NEJMp1402780.
Legality of Denying Access to Medication Assisted Treatment In the Criminal
Justice System, (December 1, 2011), by the Legal Action Center, available at
http://lac.org/wp-content/uploads/2014/12/MAT_Report_FINAL_12-1-2011.pdf.
63
Notes
66
Research. Development.
Justice. Reform.
520 Eighth Avenue, New York, New York 10018
P 646 386 3100 F 212 397 0985 courtinnovation.org

MAT in Drug Courts: Recommended Strategies

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

MAT in Drug Courts: Recommended Strategies

Uploaded by

Copyright:

Available Formats

MedicationAssisted

Medication-Assisted Treatment in Drug Courts

About the Legal Action Center

About the Center for Court Innovation

About the New York State Unified Court Systems Office

Medication-Assisted Treatment in Drug Courts

II. Nine Components of Successful MAT Programs

III. Court Profiles

Central New York Treatment Court

Serving a mid-size city and nearby suburban and rural areas.

Upstate Treatment Court 29

Downstate Urban Treatment Court 38

IV. Specific Issues for Rural Courts

Medication-Assisted Treatment in Drug Courts

.BE IT RESOLVED THAT:

National Association of Drug Court Professionals

Medication-Assisted Treatment in Drug Courts

[T]he World Health Organization has come out strongly in support of

A Close Look at 10 Courts

Medication-Assisted Treatment in Drug Courts

What is Medication-Assisted Treatment?

Medication-Assisted Treatment in Drug Courts

withdrawal symptoms. Buprenorphine is almost always combined with

or buprenorphine as part of their treatment.10 Another showed a 75 percent

Does MAT substitute one drug for another?

How is the appropriate dose determined?

Medication-Assisted Treatment in Drug Courts

How long should someone receive MAT?

Are there risks to requiring someone to taper from MAT?

How much does MAT cost, and is it covered by Medicaid

Where can I get more information?

Medication-Assisted Treatment in Drug Courts

II. Nine Components of Successful MAT Programs

Nine Components of Successful MAT Programs

1. Counseling and other servicesplus medication

2. Courts are selective about treatment programs and

3. Courts develop strong relationships with treatment

Medication-Assisted Treatment in Drug Courts

4. Screening and assessment must consider all clinically

5. Judges rely heavily on the clinical judgment of

6. Endorsement of medication-assisted treatment by all

II. Nine Components of Successful MAT Programs

clinical decisions as the province of clinicians. Education about MAT, whether

7. Monitoring for illicit use of medication-assisted

Medication-Assisted Treatment in Drug Courts

8. Medications for medication-assisted treatment are

9. Medication-assisted treatment operates very similarly

Medication-Assisted Treatment in Drug Courts

Central New York Treatment Court

Which opioid treatment does the court use?

III. Court Profiles

Methadone: Currently, only a few participants receive methadone

Who makes treatment decisions?

Medication-Assisted Treatment in Drug Courts

to a state-licensed treatment program for a more in-depth assessment.

What services does the court require in addition to MAT

III. Court Profiles

How long do participants stay on medication-assisted

How does the court monitor compliance and illicit use of

Medication-Assisted Treatment in Drug Courts

an antagonist medication, not an opioid, and typically is injected monthly by

III. Court Profiles

Medication-Assisted Treatment in Drug Courts

How does the court respond to non-compliance and